A Stricter Approach for Commotio Cordis in Lethal Cases

Rom J Leg Med, 2010

Cardiac contusions (contusio cordis) usually appear in penetrating thoracic trauma or high energy blunt trauma and only rarely in thoracic blunt trauma in homicidal context. The diagnosis could be easy if a traumatic context is/can be proven; if not the differential diagnosis with myocardial infarction, other causes of cardiac hemorrhages or post resuscitation cardiac trauma can be very difficult, as there are no specific tests for contusio cordis. We describe in this article a case of contusio cordis in a 31 year old male, caused by thoracic blunt trauma (hit with a wooden object) and discuss some particularities of this illness and its differential diagnosis.

The American Journal of Forensic Medicine and Pathology, 2008

Commotio cordis is a term used for cases of sudden cardiac death due to nonpenetrating chest trauma without evidence of underlying myocardial disease or injury. Contusio cordis has been reserved for cases of chest trauma where there is cardiac bruising. Three deaths due to blunt cardiac and chest trauma after vehicle accidents are presented where the only significant injuries were contusions of the heart and fractures of the sternum and ribs. One case had moderate coronary artery atherosclerosis and another had a blood alcohol level of 0.218%. Given that individuals with cardiac bruising, chest trauma, coronary atherosclerosis, and alcohol intoxication may still die of the same mechanisms as in classic commotio cordis, and that these entities represent a spectrum of findings after chest impact, it may be more useful to separate cases into related subcategories: (A) those with no evidence of injury or underlying cardiovascular disease, (B) those with chest wall fractures, chest wall contusions and/or cardiac contusions, and (C) those with underlying cardiovascular disease or the presence of substances such as alcohol or drugs that may reduce the threshold for cardiac arrhythmias. As there may be cases with a number of these factors, a fourth category (D) includes those with a combination of injuries and predisposing factors (ie, categories B and C). Including cases such as these under the diagnostic umbrella of commotio cordis may demonstrate that a wider range of individuals are at risk for death from blunt cardiac trauma than sports-playing adolescents.

Journal of Cardiovascular Electrophysiology, 1999

Blunt Chest Impact Leading to Cardiac Arrest. Not particularly well recognized are athletic Held catastrophes in which virtually instantaneous cardiac arrest is produced by nonpenetrating chest blows in the absence of heart disease or identifiable morphologic injury to tbe chest wall or heart (commotio cordis). To better characterize the clinical profile of this syndrome, we have assembled 70 cases, including 34 occurring during organized competitive athletics and 36 others tbat occurred during informal recreational sports at bome, scbool or tbe playground, or during nonsporting activities. Ages were 2 to 38 (mean age: 12) witb 70% < 16 years old. Most common sports involved were youtb baseball (n = 40), softball (n = 7), and ice hockey (n = 7). Seven (10%) of the 70 commotio cordis victims, including six with documented ventricular fibrillation, have survived tbe consequences of their chest blow. Eleven of tbe events (16%) occurred despite the presence of cbest padding believed to be potentially protective. Four victims experienced modest cbest blows wbile in circumstances completely unrelated to sports activities; three ofthe four individuals who delivered these blows were ultimately convicted of criminal acts within the justice system. An experimental model of low-energy cbest wall impact demonstrates tbat commotio cordis events are due largely to the exquisite timing of blows during a narrow window witbin tbe repolarization phase of the cardiac cycle, 15 to 30 msec prior to the peak of the T wave.

International Journal of Cardiovascular Imaging, 2009

A 65-year-old woman without cardiovascular risk factors was involved in a car accident suffering blunt chest trauma. On arrival at hospital, vital signs were stable but she complained of chest pain. A first electrocardiogram (ECG) showed minor ST-T segment elevation in precordial leads and myocardial enzymes CPK-MB and Troponin-T were raised slightly above normal ranges. Chest computed tomography (CT) revealed no abnormalities. Initial diagnosis was cardiac contusion.

Resuscitation, 2015

Aim of the study: This study aimed to establish the incidence, number and location of CPR-related skeletal chest injuries (SCI) and to investigate the influence of age, gender, changes in resuscitation guidelines and technique of resuscitation. Methods: We analysed SCI in 2148 patients who had undergone resuscitation for non-traumatic cardiac arrest, as shown by autopsies performed at the Institute of Forensic Medicine in Ljubljana in the period 2004-2013. Results: External cardiac massage caused SCI in 86% of males and in 91% of females; sternum fractures occurred in 59% of males and 79% of females, rib fractures in 77% of males and 85% of females and sternocostal separations in 33% of males and 12% of females. The average number of all SCI per person was thus almost the same in males and females: 10.95 vs. 10.96. The percentage of patients injured and the number of SCI increased with age. Changes in resuscitation guidelines were also identified as a factor contributing to the incidence and number of SCI. No adverse effect of the use of LUCAS was found. Conclusion: It is generally considered that at least 1/3 of resuscitated patients sustain rib fractures and at least 1/5 sustains sternum fractures. However, our study showed that these injuries are much more frequent and that increased compression rate and depth cause more SCI. Since in the period 2011-2013 accompanying severe injuries occurred in only 1.85% of cases, the resuscitation technique has not yet jeopardised patient's safety, but further close monitoring is needed.

Case Reports, 2014

Resuscitation, 2004

Objective: To review the evidence on the incidence of rib and sternal fractures after conventional closed-chest compression in the treatment of cardiac arrest in adults and children, and after active compression-decompression cardiopulmonary resuscitation (ACD-CPR). Methods: Medline search and additional review of the cited literature in the articles found. Results: Reports on conventional CPR in adults suggest an incidence of rib fractures ranging from 13 to 97%, and of sternal fractures from 1 to 43%. Reports on CPR in children suggest an incidence of rib fractures of 0-2%, and no sternal fractures. ACD-CPR has been reported as causing rib fractures in 4-87%, and sternal fractures in 0-93% of cases. Conclusions: Sound methodological studies on thoracic fractures due to chest compression do not exist and the available studies cannot be compared one with another. In infants and toddlers, manual CPR rarely causes skeletal chest injuries. In adults, sternal fractures occur in at least one-fifth and rib fractures as well as rib and/or sternal fractures in at least one-third of the patients during conventional CPR. There is no compelling evidence to show that an increased complication rate is associated with ACD-CPR. Rib or sternal fractures are unlikely to increase mortality, as they rarely cause severe internal organ damage. Further prospective studies are desirable to assess complications by post-mortem examinations that explicitly address them. In particular, clinical evaluation of mechanical CPR devices should be accompanied by a thorough assessment of the associated complications because data specific to this modality are not available.

Forensic Science International, 2008

Commotio cordis is a clinic-pathological syndrome related to sudden death in young people involved in sports activities. It has been described, mainly, in athletes without previous cardiac anomalies who received a minor blow to the chest which produces ventricular fibrillation and cardiac arrest in the absence of structural damage to the ribs, sternum, or heart. There are few reported cases of commotio cordis associated with violent, non-sports related actions, which are commonly considered to be imprudent homicides. We present the case of a 20-year-old man, who was kicked in the chest during a fight; he suddenly collapsed although advanced cardio-respiratory resuscitation started shortly. Autopsy showed no cardiac lesions concluding that death was due to commotio cordis (blunt trauma to the chest). Toxicological analysis determined the presence of 5.14 mg/L benzoylecgonine in blood. On the basis of medico-legal investigation, the official prosecution considered the death to be imprudent homicide and the aggressor was sentenced to 4 years in prison. We emphasize the importance of the knowledge of the death circumstances through the witnesses' testimony, prior to beginning the autopsy, to confirm this important medico-legal diagnosis. Arrhythmogenic effects of cocaine and its contribution in the production of these deaths are also exposed. #

2017

Sartre is a neglected figure in contemporary philosophy, even in the Continental tradition of which he was such an important part. One important reason for Sartre's neglect in this tradition (and not just there) is his eclipse by Heidegger. Of course, Sartre considered himself a follower of Heidegger, so it might seem that attention to one need not detract from the other. Yet Heideggerians are often extremely reluctant to recognize Sartre as a member of their camp. For followers of Heidegger, Sartre is a figure who remains too "Cartesian," too much of a "philosopher of the subject" to be thought of as part of the same movement.1 Given the circumstances in which Sartre first encountered Heidegger's writings, it is reasonable to wonder if Sartre understood Heidegger sufficiently. As is well known, Sartre read Heidegger in translation, and in an anthology of his writings that was highly selective.